News and analysis · Nouvelles et analyses

CMAJ 1999;161:361-4

• Media coverage of health stories often inaccurate, MDs report
• Vinyl toys, medical devices get clean bill of health
• Good music . . . good medicine
• New aid for breast self-exam
• Dalhousie's ER doctors given departmental status
• Pulse: Looking for an alternative
• Research Update
  • Spironolactone saves lives in heart failure
  • A new weapon against androgen-independent prostate cancer
  • Sale of anonymous prescription data breaches confidentiality: UK court

Canadian physicians think journalists could be doing a better job reporting on health issues, according to a recent survey. The random poll of 250 general practitioners, conducted in May, revealed that only 34% believe the news media are delivering accurate coverage of medical health information. Despite the less-than-glowing assessment of journalists' efforts, nearly 75% of respondents said health-related news items are beneficial because patients often ask questions about them, which indicates that they are trying to learn more about their health.

Bad news: 66% of GPs surveyed believe media coverage of medical science news is often inaccurate

Just over a quarter of the physicians polled said patients arrive at least once a day with questions based on media stories. Another 44% reported receiving such queries at least once a week.

Results of the survey, which was commissioned by the Canadian Science Writers Association (CSWA) and financed by Bayer Inc., were presented at the CSWA's annual conference in late May.

Dr. Michael Evans, an assistant professor in the University of Toronto's Department of Family and Community Medicine and staff physician with Toronto's University Health Network, said ever-increasing medical news coverage — much of it fuelled by the drug industry's "PR machine" — is a double-edged sword.

"On the one hand, we have people coming into the office asking for the latest arthritis drug when they haven't even tried Tylenol yet," says Evans, who has a special interest in health and the mass media. "On the up side, though, thanks to Viagra, we have men coming in and talking about their sexual health for the first time."

Of the physicians who reported that health stories influence patients' questions (n = 216), 82% said requests were based on a misunderstanding of the research or findings that were reported. Close to a third of doctors blamed this on poor media coverage, while 54% chalked it up to patients simply failing to understand the material.

Physicians reported that poor reporting of medical stories was primarily due to the media's desire to grab audience or reader attention (41%), followed by journalists' limited knowledge of the subject matter (31%) and limited time available to research and prepare stories (14%).

General practitioners gave journalists the highest marks for coverage of the results of clinical trials (32% reported such coverage was good/excellent) and the lowest marks for distinguishing clearly between incremental medical advances and those with real clinical significance (13% chose good/excellent).

Training for reporters in the basics of medical research is the key to improving the quality of news coverage, according to 88% of physicians surveyed. The CSWA is currently planning a series of seminars in an attempt to equip journalists to cover the health beat. — © Greg Basky, Saskatoon

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Vinyl softeners used in medical devices and children's toys have been deemed safe by an independent, nonprofit group of US researchers. The finding directly contradicts another study from an international consortium of 180 organizations, including the American Nurses Association.

The American Council on Science and Health (ACSH), which is dedicated to "helping Americans distinguish between real and hypothetical health risks," formed a 17-member expert panel in February to look at the safety of 2 plasticizers. Di-2ethylhexyl-phthalate (DEHP) is the primary plasticizer used in many medical devices; di-isononyl phthalate (DINP) is present in soft vinyl toys.

"Consumers can be confident that vinyl toys and medical devices are safe," stated former US surgeon general Dr. Everett Koop, who chaired the panel. "There is no scientific evidence that they are harmful to children or adults."

However, Health Care Without Harm (HCWH), whose member organizations include Greenpeace, 41 hospitals and the American Public Health Association, commissioned another comprehensive review of the scientific literature. That report, The use of Di-2ethylhexyl-phthalate in PVC medical devices: exposure, toxicity and alternatives, concluded that "humans are exposed to substantial levels of DEHP through medical devices." According to Dr. Tee Guidotti of Edmonton, founder of the Canadian Association of Physicians for the Environment and a member of HCWH, "sick patients with lots of treatments are exposed to high levels of DEHP, and because they're sick, it may make them more susceptible to DEHP."

But Koop's group examined 86 scientific reports and its report, A scientific evaluation of health effects of 2 plasticizers used in medical devices and toys, concluded that DEHP in medical devices is not harmful. In fact, it "imparts a variety of important physical characteristics that are critical to the function of medical devices. Eliminating DEHP in these products could cause harm to some individuals."

Under the Canadian Environmental Protection Act, DEHP is classified as "unlikely to be carcinogenic to humans," although because of limitations in the database, classification as "possibly carcinogenic to humans" may also be appropriate.

The ACSH panel found fewer scientific reports (36) concerning DINP but concluded that it is not harmful for children in the "normal use of these toys." The panel did recommend further study to document children's contact time and mouthing behaviour involving toys and other objects, and the rates of release of DINP under realistic conditions. In November 1998, Health Canada advised parents to discard teethers and rattles made of PVC and asked toy manufacturers to phase out the use of DINP.

The full ACSH panel report is available at www.medscape.com, and a summary of the HCWH report is online at www.noharm.org.

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Thirty years ago, Ron Stewart and 2 of his classmates produced a musical variety show that has since become a yearly event at Dalhousie University's School of Medicine. Thirty year later, Stewart, a former minister of health in Nova Scotia who now teaches emergency medicine at Dalhousie, has once again spearheaded a bit of medical school musical magic.

Good music . . . good medicine, a new chorale, band and string ensemble, gives medical students a musical oasis away from the rigours of medical education. Response has been overwhelming, with nearly 100 medical students, many in their first year, eager to attend rehearsals. Many of the students are delighted that their musical talents need not be put on hold during medical school.

The program also opens up new research opportunities for students. It is funded by an endowment named in honour of Dr. Bernard Badley, who recently retired after spending 20 years as conductor of the medical school's Tupper Band. Stewart, the endowment's chief fund-raiser, hopes to raise $350 000 over the next 5 years to cover the modest expenses of the band, string ensemble and choir, and to fund several student research projects every summer. The latter will focus on the positive impact music is believed to have on health. This year, 2 students will be researching the effects of music on the lifestyles of older people living in seniors' residences.

Stewart hopes other medical schools eventually adopt the Good music . . . good medicine concept. He is also rather proud of the program's logo, which he conceived.

Stewart, who plans to host a world seminar on music in medicine in Halifax next year, is convinced one of the significant spin-offs of this kind of event will be the production of more physicians who find music personally fulfilling and will be eager to help identify the possible untapped benefits that music can have on patient care and many aspects of contemporary medicine. — © Dorothy Grant, Halifax

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Only 25% of Canadian women conduct a monthly breast self-examination. Two excuses predominate among the other 75%: limited tactile sensitivity and discomfort with touching themselves. Now a new "Sensability" pad from Becton-Dickinson attempts to address these issues. The pad consists of 2 thin plastic sheets with a liquid lubricant sealed between them. It reduces friction between a woman's fingers and her breasts by clinging lightly to the skin. The pad comes complete with an instructional video and written instructions. Call 800 268-5430 for information.

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The Division of Emergency Medicine at Dalhousie University has become only the second in Canada to receive departmental status. The move, approved by the university's Board of Governors in June, means that Dalhousie joins Queen's University in having a full-fledged Department of Emergency Medicine.

Dr. Douglas Sinclair, who will head the new department, said there are great variations in the way academic emergency medicine is treated across the country. "I think this is another sign of the maturing of the specialty and recognition of the work we are doing," he said, adding that the move will help put emergency doctors on an equal footing with other specialists, such as anesthetists and obstetricians.

Emergency medicine was already a free-standing division with its own budget at Dalhousie, and its budget will not grow because of its new status. "This will not change the academic and research activities we have been involved in," added Sinclair, "but it better reflects what we do. It is certainly nice to have this distinction and recognition among our peers in the academic community."

Sinclair is convinced that the Dalhousie decision will be repeated elsewhere because "emergency medicine has shown that it has a unique body of knowledge. At the moment, though, there is great variance across the country in the way the specialty is treated."

The new department has 40 part-time faculty members, spread throughout the Maritime provinces.

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A survey conducted by the Fraser Institute revealed that 73% of Canadians had used at least one alternative therapy at some point in their life. Chiropractic was the most common therapy used, being cited by 36% of respondents, followed by relaxation techniques and massage at 23%. Prayer was cited by 21% of respondents.

Exactly half reported using at least one alternative therapy in the previous 12 months, but within this group only 44% discussed this fact with their physician. More than half of these respondents (53%) felt it was unimportant for their doctor to know and 39% thought that it was none of their doctor's business. Some (22%) thought their doctors would not approve and 21% felt their physician would discourage them from seeking alternative care. Most (72%) believed that using alternative medicine in combination with conventional medicine is better than using either alone.

Canadians spend an estimated $3.8 billion on alternative medicine every year. This includes provider fees ($1.8 billion), books, medical equipment, herbs, vitamins and special diet programs; $3.8 billion accounts for more than 16% of all private health care expenditures in 1995. By way of comparison, total annual capital expenditures in Canada's hospitals stood at $2.1 billion in 1995.

Most respondents (60%) felt that alternative medicine should not be covered by provincial health plans but should remain a private expense.

Survey of people seeing a medical doctor or other provider for conventional or alternative medical care Source: Alternative Medicine in Canada, The Fraser Institute, 1999

This column was written by Lynda Buske, Chief, Physician Resources Information Planning, CMA. Readers may send potential research topics to Patrick Sullivan (sullip@cma.ca; 613 731-8610 or 800 663-7336, x2126; fax 613 565-2382).

   | Other Pulse articles / Autres chroniques Médicogramme |

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The aldosterone antagonist spironolactone cuts the risk of death and the rate of hospitalization by one-third in patients with severe heart failure, according to a large international study. The multicentre study was stopped earlier than planned and its results have been released on the Internet (www.nejm.org) before print publication in the New England Journal of Medicine.

The Randomized Aldactone Evaluation Study was conducted in 15 countries on 5 continents, with 1663 patients enrolled in 195 centres. Patients had a ventricular ejection fraction of 35% or less and were receiving standard therapy for heart failure — an angiotensin-converting-enzyme (ACE) inhibitor, a loop diuretic and, in some cases, digoxin. Spironolactone or placebo were added to the regimen on a randomized basis. After follow-up lasting an average of 2 years, the mortality rate was 35% in the spironolactone group and 46% in the placebo group. Spironolactone treatment also lowered the rate of hospitalization and resulted in significant improvement in the symptoms of heart failure. The main side effect is gynecomastia and breast pain, which affected 10% of men taking the drug.

Spironolactone reduces levels of aldosterone, a steroid produced at up to 20 times the normal levels in patients with heart failure. Aldosterone contributes to the sodium retention and edema that characterize the condition. According to an accompanying editorial, "the importance of aldosterone in congestive heart failure has been overlooked in recent years" because ACE inhibitors were thought to eliminate aldosterone production. However, it now appears that ACE inhibitors suppress aldosterone only briefly.

Based on these results, the authors and editorialist recommend adding spironolactone to standard therapy for patients with severe heart failure. — C.J. Brown, CMAJ

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A discovery by a scientist at the BC Cancer Agency explains why some prostate cancer tumours grow even without androgen, foiling chemical attempts to stop them. The discovery opens up possibilities for drug therapy to fight these hard-to-control tumours.

The research, by Dr. Marianne Sadar (J Biol Chem 1999;274[12]:7777-83), focused on hormone-resistant, or androgen-independent, prostate tumours. The usual treatment for metastasizing prostate cancer is withdrawal of testosterone (androgen), also known as "chemical castration." However, some cancerous prostate cells begin to grow again even without circulating testosterone. How this happens has puzzled scientists for decades. Researchers have known for some time that the growth-promoting effect of testosterone on prostate cancer cells is mediated by the androgen receptor — a protein that is switched on when it binds to testosterone. Sadar discovered that this receptor can be activated without testosterone, a process that may underlie androgen-independent tumour growth. This is occurring in a new region of the receptor, she says, by a mechanism that "we are still figuring out." She and her colleagues are now mapping the androgen receptor sites to find where the receptors are being activated. This is a first step in designing drugs to act as decoys for the receptor. Any new drug would be used in combination with conventional hormone withdrawal therapy. "When the patient is on androgen withdrawal therapy, we should be able to control the cell so that we can control androgen-independent disease," says Sadar.

Dr. Nicholas Bruchovsky, head of the BC Cancer Agency's Department of Cancer Endocrinology, says that "the loss of response to treatment is one of the major stumbling blocks that limits the effectiveness of today's therapies. Dr. Sadar's discovery has opened up a whole new approach to possible cures." — © Heather Kent, Vancouver

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A recent decision by the United Kingdom's High Court has called into question the assumption that the use of facts and figures gleaned from a physician's prescription data does not constitute a breach in confidentiality. The May 1999 court case in London is thought to be the first to deal with patient information that has been rendered anonymous. Mr. Justice Latham ruled that patients' implied consent covered use of their data for treatment and related purposes only, not for sale to pharmaceutical companies. The case arose after Source Informatics, a US-based company that operates a prescriber database for pharmaceutical companies, sought to approach GPs with promotions and information about their products. The GPs had refused to allow their prescription details to be supplied to the database. Source Informatics was given permission to appeal the judgement because the ruling "raises issues of huge importance for the law of confidentiality."

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© 1999 Canadian Medical Association (unless otherwise indicated)